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  • Enrollment Application

    Thanks for your interest in becoming a patient. If you need help, call us at 540-536-1614.
  • We're sorry, you cannot become a patient with Sinclair Health Clinic.

    We cannot treat individuals whose primary residence is outside of Virginia.
  • We're sorry, you cannot become a patient with Sinclair Health Clinic.

    We do not treat individuals with Medicare or private insurance. We suggest you call our colleagues at Shenandoah Community Health (540) 722-2369 or visit them online at https://www.shencommhealth.com/
  • Your IDENTIFICATION Information

    Provide photo ID or other proof of identification.
  •  -  - Pick a Date
  • Upload ID Image
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  • TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Verify Your Virginia RESIDENCY.

    Please select from the choices below
  • Your Address and Residency Verification

    Please provide information and proof of your Virginia residency
  • When you have completed this section, please click NEXT to continue.
  • TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Contact and Information

    Please provide all your contact information including how you prefer to be contacted about your appointments and other communications from us.

  • Information About You.

    Please provide more information about you. When you have completed this section





  • We're sorry, you cannot become a patient with Sinclair Health Clinic.

    We need to discuss your current health benefits with you. We do not accept patients currently receiving VA healthcare. Please stop this application and give us a call to discuss (540) 536-1614. Thank you.
  • When you have completed this section, please click NEXT to continue.
  • Determining the Number in Your Household

    We define your household as YOU, a spouse, and any dependents (those individuals you do or would list on your tax return), if applicable.
  • Your Household Income: The APPLICANT (You)

    Please provide the information below to help us determine your household income. You must provide proof of income for all dependents in your household.
  • Upload your weekly pay stubs for the past 30 days

    Please upload images or scans of your pay stubs. If you paychecks are direct deposited into your account, upload your electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload your bi-weekly pay stubs for the past 30 days

    Please upload images or scans of your pay stubs. If you paychecks are direct deposited into your account, upload your electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload last month's pay stub

    Please upload images or scans of your pay stubs. If you paychecks are direct deposited into your account, upload your electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Self Employment Income

  •  
  • I      , do hereby certify that all the above income information for the past 3 months is true and correct.

       
    Pick a Date   

  • Need Employer to Verify Income

    Your employer need to fill out the Employee Payroll Verification form. Continue with the application and we will send you the form after your application is submitted.
  • Receiving Unemployment

    Please upload the most current official unemployment benefit letter that shows the amount you are receiving.
  • Browse Files
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  • When you have completed this section, please click NEXT to continue.
  • Receiving Other Benefits

    You are seeing this section because you indicated you were receiving income from other state, federal or court mandated sources (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support). Please upload the official letters from each source showing the amount of benefit income you are receiving.
  • Browse Files
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  • When you have completed this section, please click NEXT to continue.
  • No Income Certification

    You are seeing this section because you indicated you are not currently not making any income of any type.
  • I,        , certify that I do not receive income from any of the following sources: 

    • Wages from employment (including commissions, tips, bonuses, etc.);  
    • Rental income from real or personal property;  
    • Interest or dividends from assets;  
    • Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits;  
    • Unemployment
    • Periodic allowances such as alimony, child support.  

     

    Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.


       

    Pick a Date   


    When you have completed this section click NEXT to continue.

  • TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Household Income: Your SPOUSE/Legal Partner

    You are seeing this section because you indicated that you are married (you are not required to submit income for a spouse from whom you are legally separated) You must provide proof of income for your spouse/legal partner in your household.
  • Upload your weekly pay stubs for the past 30 days

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload your bi-weekly pay stubs for the past 30 days

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload last month's pay stub

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Self Employment Income

  •  
  • I       (spouse/legal partner), do hereby certify that all the above income information for the past 3 months is true and correct.

       Spouse/Legal Partner
    Pick a Date   

  • When you have successfully completed this section, please click NEXT to continue.
  • Need Employer to Verify Income

    The employer need to fill out the Employee Payroll Verification form. Continue with the application and we will send you the form after this application is submitted.
  • Receiving Unemployment

    Please upload the most current official unemployment benefit letter that shows the amount they are receiving.
  • Browse Files
    Cancel of
  • When you have completed this section, please click NEXT to continue.
  • Receiving Other Benefits

    You are seeing this section because you indicated your SPOUSE/Legal partner is receiving income from other state, federal or court mandated sources (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support). Please upload the official letters from each source showing the amount of benefit income being received.
  • Browse Files
    Cancel of
  • When you have completed this section, please click NEXT to continue.
  • No Income Certification

    You are seeing this section because you indicated your SPOUSE/Legal Partner is currently not making any income of any type.
  • I,        (SPOUSE/Legal Partner), certify that I do not receive income from any of the following sources: 

    • Wages from employment (including commissions, tips, bonuses, etc.);  
    • Rental income from real or personal property;  
    • Interest or dividends from assets;  
    • Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits;  
    • Unemployment
    • Periodic allowances such as alimony, child support.  

     

    Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.


       SPOUSE/Legal Partner

    Pick a Date   


    When you have completed this section click NEXT to continue.

  • TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Other Members of Your Household Making Income

    Please provide proof of income for ALL adult members of your household receiving actual income. DO NOT LIST dependant children under the age of 18.
  • TIP:

    Only report members of your household receiving income.
  • Your Household Income: Dependent Income (1)

    Please provide the information below to help us determine your household income. You must provide proof of income for members of your household who are receiving income.
  • Upload weekly pay stubs for the past 30 days

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload bi-weekly pay stubs for the past 30 days

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload last month's pay stub

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Self Employment Income

    Please report your self employment income for the past 3 full months. Click the ADD PREVIOUS MONTH button to add the next month.
  •  
  • I       (dependant), do hereby certify that all the above income information for the past 3 months is true and correct.

       Dependant
    Pick a Date   

  • When you have successfully completed this section, please click NEXT to continue.
  • Need Employer to Verify Income

    The employer need to fill out the Employee Payroll Verification form. Continue with the application and we will send you the form after this application is submitted.
  • Receiving Unemployment

    Please upload the most current official unemployment benefit letter that shows the amount they are receiving.
  • Browse Files
    Cancel of
  • When you have completed this section, please click NEXT to continue.
  • Receiving Other Benefits

    You are seeing this section because you indicated the Dependent is receiving income from other state, federal or court mandated sources (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support). Please upload the official letters from each source showing the amount of benefit income being received.
  • Browse Files
    Cancel of
  • When you have completed this section, please click NEXT to continue.
  • TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Your Household Income: Dependent Income (2)

    Please provide the information below to help us determine your household income. You must provide proof of income for your spouse/legal partner in your household.
  • Upload weekly pay stubs for the past 30 days

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload bi-weekly pay stubs for the past 30 days

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload last month's pay stub

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Self Employment Income

  •  
  • I       (dependant), do hereby certify that all the above income information for the past 3 months is true and correct.

       Dependant
    Pick a Date   

  • When you have successfully completed this section, please click NEXT to continue.
  • Need Employer to Verify Income

    The employer need to fill out the Employee Payroll Verification form. Continue with the application and we will send you the form after this application is submitted.
  • Receiving Unemployment

    Please upload the most current official unemployment benefit letter that shows the amount they are receiving.
  • Browse Files
    Cancel of
  • When you have completed this section, please click NEXT to continue.
  • Receiving Other Benefits

    You are seeing this section because you indicated the Dependent is receiving income from other state, federal or court mandated sources (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support). Please upload the official letters from each source showing the amount of benefit income being received.
  • Browse Files
    Cancel of
  • When you have completed this section, please click NEXT to continue.
  • TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Your Emergency Contact Information

    The person we should call in the event of an emergency.

  • PHARMACY: Supplemental Documents and Terms and Conditions

    The documents request below are NOT necessary to become a patient of the clinic, but it will help the pharmacy at Sinclair Health Clinic provide you with reduced cost medications. Please read, acknowledge, sign, and date the below terms and conditions.
  • Browse Files
    Cancel of
  • *   
    Pick a Date*   

  • How did you hear about us?

  • Patient Disclosure and Consent

    Please read, sign, and submit your completed application.
  • *   
    Pick a Date*   

  • APPLICATION with MEDICAID

    You are seeing this section because you indicated you already have Virginia Medicaid health coverage.
  •  -  -
    Pick a Date

  • Information About You.

    Please provide more information about you.





  • We're Sorry.

    We need to discuss your current health benefits with you. We do not accept patients currently receiving VA healthcare. Please stop this application and give us a call to discuss (540) 536-1614.
  • Your Emergency Contact Information

    The person we should call in the event of an emergency.

  • When you have completed this section, please click NEXT to continue.
  • We're sorry, you are not eligible to be a patient with Sinclair Health Clinic.

    We can only accept applications from adults living in Virginia who are uninsured and have the acceptable documents we require, or have proper Virginia Medicaid . If you have questions or need additional assistance, please call our enrollment office at 540-536-1614.
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